Title:
Traditional Chinese Medicine for Integrative Fertility Treatment: An Effective Therapeutic
Strategy
Authors: Nicole Hohmann MS, Dipl.OM, L.Ac, FABORM (superscript 1)
Geeta Maker-Clark, MD- (superscript 1,2,3)
Affiliation: 1. NorthShore University Health System Integrative Medicine
2. NorthShore University Health System Dept. of Family Medicine
3. University of Chicago, Pritzker School of Medicine
Abstract:
Traditional Chinese Medicine (TCM) modalities such as acupuncture and Chinese herbal medicine may
be used to successfully treat fertility issues. Integrative physicians often refer patients with infertility to
Traditional Chinese Medicine (TCM) providers for primary and/or adjunctive care to ART, but are not
familiar with the techniques implemented to create successful outcomes. The treatment strategies,
evidence base and possible mechanisms at work when combining TCM with assisted reproductive
technologies (ART) and when TCM is the primary treatment, are explored. 3 successful case reports in
our practice are highlighted.
Mechanisms and Methodology:
Acupuncture has an impact on hypothalamic-pituitary-ovarian axis and the menstrual cycle through
neuropeptides in the central nervous system, particularly beta-endorphins, and the release of hypothalamic
gonadotropin releasing hormone (GnRH) and pituitary secretion of gonadotropin. Wang, et al.(17) found
that EA increased the expression of GnRH in the medial preoptic area, the arcuate nuclei and the nuclei
periventriculares of the hypothalamus, with significantly more expression in the diestrus and the
metaoestrus of PCOS rats. Various investigators have proved that in ovulatory or anovulatory cycles,
acupuncture influences serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH),
estradiol (E2), and progesterone (P)
Acupuncture can increase the ovarian blood flow possibly due to its sympatho-inhibitory effects. After
acupuncture, sympathetic nerve activity, as measured by norepinephrine level, skin temperature, blood
pressure, and pain tolerance threshold, decreased.
In experimental rat studies, low-frequency electro acupuncture increased ovarian blood flow. The
response was mediated via ovarian sympathetic nerves as a reflex response and controlled by supraspinal
pathways. The needles were placed in the abdomen and hind limb, which have the same somatic
innervation as the ovaries and uterus. It was found that EA modulated sympathetic nerve activity in the
ovaries by decreasing ovarian concentrations of endothelin, corticotrophin-releasing factor and nerve
growth factor.
When utilizing TCM as primary treatment, Chinese herbal medicine is considered integral and
acupuncture is typically used adjunctively except when patients may opt out of herbal medicine. Chinese
herbal treatment strategies may consist of using several different formulas according to the phases of the
menstrual cycle based on interpretation of the functions of the hormones in relation to YinYang
theory. Alternatively, an herbalist may choose to treat using one or two formulas throughout the month
based on Chinese medicine pattern differentiation, or treatment may start out with a course of a single
formula for 2-3 cycles, then move to phase formulas. Acupuncture points are selected according to the
patient presentation at the time of the session as well as where the patient is in her menstrual cycle. A
retrospective analysis found Chinese herbal therapy for infertility to be twice as successful as drug
therapy or IVF over a four month period. Patients are typically followed weekly until pregnancy is
achieved which may take three to twelve months or longer.
Chinese Medicine Physiology of Fertility
Reproductive potential comes from Jing, or essence, produced by and stored in the Kidneys. Sperm and
ova are comprised of Jing. Our Jing, it is believed, declines over time as we age. The proper function of
the organs of the Liver, Spleen and Heart are all important in fertility. The Liver Qi, or vital energy,
regulates the flow of Blood and ensures a menstrual cycle by filling the Chong Mai or Sea of Blood
vessel, and the Ren Mai, the conception vessel, which traverse the uterus. The Kidney Yang energy must
be strong enough to burst the egg from the follicle. The Spleen generates Blood which ultimately
nourishes the follicle and the lining. The Kidney Yin is related to the substance and quality of the follicle
itself and the cervical mucous and is often correlated to estrogen. The Heart communicates with the
Kidney and controls the Blood. The Heart houses the Shen, translated as mind or spirit, and may be
thought of as the hypothalamus and pituitary function. If the Shen is disturbed by stress, lack of Blood or
other imbalance, the Heart's communication with the Kidney falters and may hinder conception. The
Kidney Yang has a holding-in quality and thus supports the uterus during the implantation process.
Progesterone is closely associated with Kidney Yang. The uterus is called the Bao Gong, encompasses the
ovaries and fallopian tubes, and is connected to the Heart via the Bao Mai or uterus vessel, and with the
Kidney via the Bao Luo, or uterus channel.
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Phases of the menstrual cycle and Chinese medicine treatment:
The following concept of treating according to the phases was developed by reproductive specialists in
Nanjing, China and was widely popularized in the West by authors Jane Lyttleton and Giovanni Maciocia
who studied in Nanjing as did the author of this article. The development of the cervical mucous and the
BBT chart can be used to determine which days to begin and end each phase according to the individual's
cycle. In China, TCM physicians may use ultrasound data as well. (1,2)
Period phase: Days 1 through 4 or 5
During the shedding of the endometrium the Qi and Blood must move freely in order to shed the
endometrium completely and smoothly without excess bleeding, clotting or pain. Herbs to move Qi and
Blood may be given at this time, or herbs to stop bleeding or strengthen the Qi and Blood if there is
deficiency or scant flow. Acupuncture point prescriptions will mirror this treatment strategy. A proper
cycle according to TCM is 3-5 days, red color, not purple or pale, neither too heavy nor too light, without
pain or clotting and without much spotting before or after the flow and comes every 28 days plus or
minus a few days.(2)
Post-period phase: Days 4 or 5 through 9 or 12
The development of the follicle and the production of fertile cervical mucous is attributed to the Yin of
the Kidney and the development of the new lining attributed to the Yin and Blood. Herbs and acupuncture
points to help build the Kidney Yin and Blood may be administered and Yang herbs may be added if the
woman is more advanced in age or has signs of Yang deficiency.
Ovulation Phase: Days 10 or 12 through 16 or 17
During ovulation, the Yin substance of the egg reaches its maximum and Yin must transform into Yang
for the egg to burst forth from the follicle. Cysts, even benign physiological ones such as the follicle, are
seen as a type of Blood stasis and herbs to move Blood are given to help promote the
normal transformation of the follicle. Thus treatment is focused on boosting the Yang and moving the
Blood starting days before ovulation.
Post-ovulation Phase: Day 16 or 17 until period or confirmed pregnancy
For successful implantation, we need an abundance of Blood to grow the lining of the uterus and nourish
an embryo and Yang energy to secure the embryo in place and warm the womb. Yang is warming in
nature and abundant Yang will assure basal body temperatures to remain elevated as they should. Points
and herbs that move Qi and Blood are typically removed from the treatment strategy at this time.
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Case Study: EA
A newly married 43 year old woman sought treatment after trying to conceive for 5 months. She had
consulted with an RE, had a normal HSG and her husband had a normal semen analysis. Her FSH, TSH,
LH, prolactin, and estradiol labs were all normal. She had received 5 acupuncture treatments for lower
back pain from the referring acupuncturist prior to referral here. She tried Clomid for one cycle
unsuccessfully.Menses were regular, every 24-27 day cycles with 5 days of flow, and heavy on the first
day only. Sometimes she had mild cramps with ovulation and with her period. Urine LH home test strips
showed surges typically on days 10-12. She noted no cervical mucous with ovulation but typically would
get it one week after ovulation. She complained of stress about her fertility situation and was considering
IVF. Medical history included vertigo, lower back pain, hypoglycemia and long standing insomnia. She
reported not much exercise. Her nails were ridged. She denied hot or cold sensations or preferences.
Tongue: enlarged, slightly pale, dry white coat
Pulse: thready and slightly wiry
Assessment: Kidney Jing deficiency leading to age related subfertility.
Treatment:
Herbal medicine according to phases:
Period phase:
No herbs during period since she had a fairly normal menstruation.
Post-period phase:
Days 3-9. Nourish Essence by Golden Flower Herbs 3 tabs twice per day to increase Kidney Yin, Yang,
Qi and Jing
Ovulation phase:
Days 10-15. Mobilize Essence by Golden Flower Herbs 3 tabs twice per day to increase Kidney Yang
and move Blood
Post-ovulation phase:
Days 16- end of cycle. Yuan Support by Golden Flower Herbs 3 tabs twice per day to boost Kidney Yang
and nourish Blood.
Acupuncture points:
Points were selected according to patient presentation and phase of cycle:
Yintang, Ear Shenmen, Ear Endocrine, Lung 7, Kidney 6, Pericardium 6 and Spleen 4, Liver 3, Kidney 3,
Stomach 36, Ren 4, Stomach 29, Zi Gong, Du 20
Outcome:
Over a ten month period, she had 21 acupuncture treatments and took the herbs as prescribed and decided
not to pursue IVF. Her cervical mucous was now evident earlier in her cycles prior to and around
ovulation. In June of 2011, ten months after her first treatment, she became pregnant. Once pregnant, she
discontinued herbs and continued acupuncture treatment through her 23rd week of pregnancy. During
pregnancy no acupuncture points were used in the lower abdomen as these are customarily
contraindicated. She carried to term and gave birth to a healthy baby boy.
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Treatment according to TCM pattern diagnosis (non-phase treatment)
Sometimes it makes sense clinically not to treat with the phases especially in the case of PCOS when
cycle length is very long or variable and changes in the phases may be less distinct. A patient coming off
of drug treatment may need to be balanced and restored from the stagnation from the fluctuating
supraphysiologic hormones caused by ART and the emotional toll of biomedical infertility
treatment. When a patient's imbalance is primarily one of dysregulation of Qi and Blood versus a Kidney
deficiency, continuous formulas may be a successful choice.
Case study: IH
A 32 year old woman presented for TCM after three and a half years of trying to conceive. She had been
diagnosed with PCOS nine months previously. She tried Clomid six months prior to her first acupuncture
appointment and experienced side effects of profuse night sweating, hot flashes and trouble sleeping. Her
menstrual cycles were 40-54 days long with five days of flow, starting with two days of heavy flow. She
noticed white cervical mucous one week prior to her periods. She also complained of stress, difficulty
sleeping, headaches and acne. She had just moved to a new apartment, her husband was applying for jobs
out of state and she was a PhD student. She had a history of reflux for the past six years managed by diet
and tended toward constipation, bloating and abdominal pain. She was experiencing anxiety and
spontaneous sweating. She lacked thirst and her water intake was very low.
Tongue: pale red, swollen with a thick white coat.
Pulse: was weak and slightly wiry.
Assessment:
Liver Qi stagnation with Heat and Dampness, Spleen Qi and Blood deficiency and Shen disturbance.
Treatment:
Chinese herbal medicine:
Bupleurum and Peony capsules by Sun Ten Herbs. 6 capsules twice per day to harmonize Liver, boost
Spleen Qi and Blood, and clear damp heat
Zizyphus 18 tablets by Seven Forest/Institute for Traditional Medicine. 3 tabs twice per day to calm the
Shen, nourish Kidney, Liver, Spleen and Heart
Acupuncture:
Yintang, ear Shen men, Liver 3, Large intestine 4, Ren 4, Zi Gong, Stomach 36, Spleen 6
Outcome:
She received 12 treatments over the next five months and complied with the herbal recommendations. She
felt very relaxed from the treatments and noticed her complexion and sleep improved. During her first full
cycle treated with TCM she noticed egg white cervical mucous for the first time, corresponding with the
day before her home ovulation monitor indicated ovulation. The next three cycles were all 35 days in
length and on the fifth month of treatment she reported that she was pregnant. She had a healthy
pregnancy and gave birth to a baby boy.
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Acupuncture and ART Combination Treatment
When combined with ART, acupuncture is ideally started months prior to embryo transfer to ready the
patient for conception. In cases where the patient comes late to TCM in her infertility treatment,
acupuncture sessions can be given twice or three times per week prior to transfer aiming for a minimum
of 9 sessions. In one study pregnancy rates increased as number of acupuncture treatments increased
beyond 8 sessions. In trials in which acupuncture was used only once or twice around egg retrieval or
embryo transfer, pregnancy rates were not enhanced. Optimally treatment begins weekly three months
prior to IVF in order to affect the egg on the level of the Jing, and to give time for treatment to regulate
the functions and vitality of the Spleen, Kidneys, Liver and Heart. In the author's experience, spreading
the treatments out over time helps the woman prepare emotionally and physically and allows time to
return her to a state of balance after previous ART treatments. Treatment may include the SteinerVictorin protocol to increase uterine blood flow during follicle stimulation and the Paulus study protocol
before and after transfer of the embryo, or the practitioner may tailor the treatment to the individual
situation and pattern in accord with TCM principles. Acupuncture in combination with IVF may increase
not just pregnancy rates, but live birth rates and reduce miscarriage rates.
Case study: JH
A 32 year old woman sought treatment after trying to conceive for 3 years. She had a history of
asymptomatic pituitary microadenoma and pineal gland cyst. She had a laparoscopy two months prior to
her first visit and a small lesion of endometriosis was found on her bowel which she reported her doctor
did not remove as she did not feel it was significant enough to cause infertility. Genetic testing revealed a
mild thrombophilia due to a heterozygous mutation of the prothrombin gene. She had completed six IUI
cycles and was on birth control pills at the time of her first visit in preparation for her first IVF.
Menstruation was every 28 to 30 days. Her cycles were up to 33 days long since starting fertility
medicines. Periods were typically 3 days long with clots but no cramps and no premenstrual symptoms.
She had a history of anxiety and depression for ten years. Energy level was low and she usually slept
well but lately was having difficulty due to stress from infertility. She had side effects of fertility
medications that included severe bloating. She tended to constipation and felt cold in general, though
recently was feeling hot.
Medications and supplements included Zoloft, baby aspirin, Zyrtec, Vitamin D, folic acid, and a
multivitamin.
Tongue: pale, purple, red tip, thin white coat
Pulse: weak, choppy.
Assessment: Qi and Blood deficiency with Liver Qi stagnation and Blood stasis.
Treatment:
Acupuncture:
Twice per week recommended until transfer in about 6 weeks
Points were chosen each week from the following (not all points used each time).
Du 20, Yintang, Ear Shen men, Large Intestine 4, Liver 3, Stomach 36, Spleen 6, Ren 4, Zi Gong,
Stomach 29, Spleen 10, Lung 7, Kidney 6, Pericardium 6, Spleen 4. Milliampere electric stimulation at 10
Herz was applied to lower abdomen points Zi Gong to Stomach 29 each time bilaterally for length of
needle retention of 20 minutes.
Post-transfer: Ear Shen Men, Du 20, Yin Tang, Lu7, Kidney 6, Stomach 36.
Outcome:
After her 10th treatment she reported she had 14 eggs retrieved, 10 of which were good quality and 7
fertilized and her lining was 10 mm thick (at least 8mm is desired). She had less bloating, was sleeping
better, and feeling much better emotionally since starting acupuncture. She had a transfer 5 days later of
2 blastocysts which was not successful. She continued acupuncture through a second round of IVF, in
which 9 eggs were retrieved, 8 were mature and 5 fertilized. She completed 9 additional treatments before
her second transfer after which she called the clinic with news of her pregnancy. She gave birth to a
healthy male at full term.
Conclusion:
Many different therapies are available for patients interested in an integrative approach to fertility. TCM
offers an evidence based modality for patients with infertility and ovulatory dysfunction that can
significantly improve pregnancy rates, both as stand alone therapy and as adjunct to ART.
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images
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